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One to two points are assigned for each type of data review or related activity, as noted in Table 2. Record discussions with other clinicians and the results of those discussions.The points accumulated for the date of service are added to arrive at a total point score, as follows: In summary, document data review and analysis thoroughly, including any independent review of imaging, tracings or specimens. Indicate which medical records were reviewed and the pertinent information gleaned from them. I will be in touch with her upon receiving the pathology report.Resources AAFP questions: org/fpm/2004/1000/p21Medicare Claims Processing Manual, section 40.2: gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c03CMS Transmittal R954CP: gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R954Suzan Hauptman, MPM, CPC, CEMC, CEDC, is the senior principal for ACE Med group specializing in auditing, assessments, coding, compliance, expert opinion, writing, reporting, and education.He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999.He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

She has served on the AAPC Chapter Association board of directors and the AAPC National Advisory Board, and sits on a number of other advisory boards throughout the industry.long with history and physical examination, the complexity of medical decision making is the third key component for documentation and coding of evaluation and management (E/M) services.Current Procedural Terminology (CPT-4®) identifies four types of complexity in medical decision making: high, moderate, low and straightforward.All billable medical procedures include an “inherent” E/M component to gauge the patient’s overall health and the medical appropriateness of the service. As such, different diagnoses are not required for reporting of the E/M services on the same date” [emphasis added].For example, if a patient has a mole removed, that procedure has an inherent E/M service, which would include general preparation such as measuring vitals, maybe updating medications, confirming the mole location and its current state, etc. The E/M visit may be prompted by a complaint unrelated to the same day procedure (different diagnoses), or the procedure could be for a condition that was evaluated during the visit, or for a chronic condition that would benefit from the additional service (same diagnoses). I have recommended she see a neurologist, and I ordered an EEG for her prior to her going to that appointment.Generally, if the E/M service is unrelated to the minor procedure (i.e., the E/M takes place for a different concern/complaint), the E/M service may be reported separately. Because the E/M service leads to the decision for surgery and hernia repair is a major surgery (90-day global period), and because the E/M occurs the day before the surgery (e.g., within the global period of the procedure), report the appropriate E/M service code with modifier 57 appended.